HomeMy Public PortalAbout9456 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76 44 (2-80) MISCELLANEOUS A P�" L I v^T I®1�/
I hereby affirm that I have a certificate of consent to Self :COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, ora certificate of Workers'Compensation Insurance,or
a certifie l copy thereof(Sec. 3800,Lab..C.)
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING S z
ADDRESS
❑ Certified copy is hereby furnished. ILDING r- 'LOCALITY
- .DRESS C�LJ�` �.�Q.S
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY CROSS ST.
Date Applicant AREST - _ DISTRIoTNO. GRO/�/,p TYPE PROC SED BY
CROSS.ST. - S `!I y(�� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (� lVl
DESCRIPTION LOT NO. BLOCK MAP A �{%,/� HIGHWAv
COMPENSATION INSURANCE (�(/(/ STATE MAJOR SE ND LOCAL y
- . NO. - NO. a.
NO. OF BLDGS. (CIRCLE)
(This section need not be_completed if 'the work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars ($.100) or-less.)
- USE OF //(�7
SIZE OF LOT - EXISTING BLDG.
I certify that in the performance of the work for which this �/' 0
permit is issued, I shall not employ any person in any manner NER F-
so as to become subject to•the Workers' Compensation Laws. jlev� . OCCUPANCY GROUP U
.DRESS L .� �C.. CLCL
Date Applicant TE
NOTICE TO APPLICANT: If, after making'this Certificate of ITY NoOCCUPANT LOAD z
Exemption, you should. become subject to the Workers'
Compensation provisions of the'Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION C] No Spec. Knowl. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic DeVIC2S El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS'BELOW) OF EXITS
9 (commencing with Section 7000) of Diyision.3 of the Busi-
ness and Professions Code, and my license is in full force and
. - PARKING
-effect
SPACES REq'D PROVIDED
License Number Lic. Class
LIMITED.TIME USE
Contractor DateDATE DATE
- FROM: TO:
I am exempt from the licensing requirements as I am'a 21'0 S7,4 Pp R'S
licensed architect or a registered professional engineer slzE OF No. OF
acting in_'my professional capacity (Section 7051, BUs- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code). FINAL APPROVAL
SENT USE OF BUILDING .� /�
Lic.or Reg'.No. Date
HOME OWNER-BUILDER DECLARATION ON LOT ANNo. OT,AND 5E ISTINSE BUILDINGS
- ,
.I hereby affirm that, I am: exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code),: NO. PARKING
)• 'SPACES PROVIDED
1, as owner of the property, will do the work and the
structure is not intended 'or offered for sale (Section
7044, Business and Professions Code).
OPOSED USE OF.BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency,
for the performance of the work for which this permit is
issued,(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED Max. occ.
Lender's Address PERMIT FEE
I certify that I have read this application and state that the
IssuarvcE FEE
above information is correct.I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representat es,of this County to enter TOTAL. FEE
upon a bove-mentione pro ty for insp n'u�pose SEE REVERSE FOR'EXPLANATORY LANGUAGE
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i ture of P mi ee ate